“MIST” Molar Uprighting with Mini Implants (TADs)

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“MIST” Molar Uprighting with Mini Implants (TADs)
“MIST” Molar Uprighting with Mini Implants (TADs)
by Dr. Jose A. Trespalacios
Dr. Jose A.
Trespalacios is
a graduate of the
Technological
University of
Mexico (1991)
and received his degree in Orthodontics
in 1996. He is a former Professor
of Orthodontics for the Periodontics
Department of the Michoacán San
Nicolas de Hidalgo University.
Introduction
Our society, increasingly aware, informed and demanding, has been a significant spearhead
in the past few years for technology to make a radical orthodontic revolution, by requiring
us to address the need for minimal patient compliance and maximal anchorage control1.
The push in this direction has resulted in the advent and popularization of self-ligating
braces, lingual braces, invisible orthodontics and of course, mini implants (TADs).
Mini implants have appeared with a promise of delivering powerful results in solving
challenging malocclusions2 that exceed the limits of conventional orthodontic procedures.
They are capable of offering solutions in various types of treatment that previously were
extremely improbable and very complicated to perform (Figures 1A-B and 2A-B). Another
reason for the popularity of mini implants is the ease of their placement within the
orthodontist’s office, without the services of another dental specialist.
Dr. Trespalacios has been invited as a
professor to teach his TADs course to
several universities in Mexico, and has
lectured on this subject in more than
10 countries. He has a private practice in
Morelia, Michoacán, since 1996. He is a
Member of the AMO, AAO and the WFO.
1A
1B
2A
Figure 1A-B: Profile change with absolute
anchorage using mini implants, a favorable
changes in lip incompetence.
2B
Figure 2A-B: Gummy smile changes after use of
mini implants.
But the reality of mini implants today is that many treatments performed with them are
based on our common sense and are somewhat empirical. This leads to the need to seek
more established proposals and better structured protocols. If we look further, it is easy to
see that when modifying our anchorage, the biomechanics change radically (Figure 3A-C).
3A
3B
3C
Figure 3A-C: Excessive retroinclination and open posterior bite due to the use of regular mechanics.
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Facing the reality of the extremely rapid growth in the use of mini
implants, there is an increasing need to create a complete system
to help the orthodontist perform different types of treatment with
these attachments (Figure 4A-D) and to avoid having common
sense as the only guide. MIST (Mini Implant Simplified Treatments)
is developed as an option to give confidence to every new user.
Molar Uprighting
Second molar impaction is a very challenging disturbance because
the vectors of movement required to upright the molar with
intrusion3 is particularly difficult to accomplish and requires proper
clinical, radiological, and biomechanical evaluation and a good
appliance selection for successful treatment results4.
The incidence of second molar impaction revealed by panoramic
radiograph studies has been reported as 0.03%5 to 0.04%6 of all
impacted teeth (Figure 20).
4A
4B
It is usually thought that the correction of mandibular molars can be
accomplished by the specialist only when orthodontic appliances
are in place, and other orthodontic problems are being resolved7.
But this is not necessarily correct. A mini implant placed in the
alveolar bone buccal to the mandibular molars can provide both
a buccally directed force and an intrusive force without any
orthodontic appliances besides a molar tube and a wire.
Patient Preparation
4C
4D
Figure 4A-D: Closing an open bite and opening a deep bite, an example of mini
implant treatments.
MIST is a system created to help in the use of mini implants
in implementing various treatments. It is designed to give
orthodontists confidence, by providing them with the experience
of many years work of the leaders in this field who have used mini
implants to obtain convincing results.
1. Select a 6 to 8 mm (Figure 5) mini implant to be placed in the
mesiobuccal area of the adjacent tooth mesially to the tipped
molar (Figure 6A-B). As we said before, one of the most reliable
mandibular buccal cortical sites is found mesial to the first
molar8. From there we can have an absolute anchorage made by
the mini implant, creating no reactive forces to the adjacent teeth,
and therefore no negative side effects9.
Figure 5: Mini implant 6 to 8 mm.
This system relies on three fundamental points:
1. Presentation of a simple and effective protocol for the placement
of mini implants, which we mainly base on the placement
protocols previously described by Dr. Jason Cope, with a few
additions. We propose the insertion in just a few chosen safe
areas which allow easy access, are comfortable for the patient
and have a high success rate for the completion of the great
majority of treatments. Following placement, it is only necessary
to perform the required biomechanics.
2. Presentation of a diagnosis classification system with mini
implant treatments so it can generate an organization of the
various treatment options. We divide the classification into
four main items: Anteroposterior, Vertical, Transversal and
Special Problems.
3. Proposals of effective biomechanics for different orthodontic
cases through simplified treatments. In the Diagnostic
classification system if we go to Vertical Problems, we will find
a subsection called molar inclination, and it proposes this
treatment to upright molars.
One of the anteroposterior Vertical Problems is the mesially tipped
molar. In the following case, the MIST system has been used to
guide the treatment process.
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5
6A
6B
Figure 6A-B: The mini implant is placed mesially from the adjacent tooth of the
tipped molar.
2. Insert between the roots perpendicular to the bone surface,
trying to position it on attached gingiva preferably 3 mm from
the buccogingival line (Figure 7A-B) to avoid harming the buccal
mucosa when we activate the system (Figure 8). From here
we can provide intrusive and distal force without any other
orthodontic appliance on the anchorage unit.
3. Mark and bend 2 mm away from the loop to 90° (Figure 11A-B).
7A
7B
Figure 7A-B: Try to have at least 3 mm from the mucogingival line to protect the
buccal mucosa.
Figure 8: Injured mucosa
caused by the attachment.
11A
11B
Figure 11A-B: 90° bend from the loop.
4. Measure the distance between the mini implant and the distal
part of the tube (Figure 12A-B).
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3. Place a mini tube from the opposite side molar in the distobuccal
face with the hook facing mesial and gingival. In case you have a
band or a tube, you can use it as long as you have wings to tie an
elastic from behind (Figure 6A-B).
Fabrication of the Wire Performed to Upright
1. Take a TMA wire bar 17×25" (Figure 9A-B).
9A
9B
12A
12B
Figure 12A-B: Protection tube between 10 to 20% larger than the distance from
the screw and the tube.
5. Cut and place a protective tube 20% larger than the previously
measured distance until reaching the anterior bend of the wire
(Figure 13A-B).
13A
13B
Figure 9A-B: 17×25" TMA wire.
Figure 13A-B: Insert the tube in the wire until it reaches the bend.
2. Make a loop with a diameter of about 2 mm in one edge
(Figure 10A-B).
6. Make a loop on the back edge of the protection tube, and leave
the arm at 45° of the internal angle. You should leave at least
5 mm after cutting (Figure 14A-B).
10A
Figure 10A-B: 2 mm diameter loop.
10B
14A
14B
Figure 14A-B: Make a loop and leave a 45° angle at the edge.
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7. Insert an elastic chain in the posterior loop (Figure 15A-B).
15A
4. Place a portion of flowable composite over the head of the mini
implant to prevent the wire to disengage (Figure 19A-B).
15B
Figure 15A-B: Insert an AlastiK™ Ligature chain in the second loop.
19A
19B
Figure 19A-B: The flowable composite can help to prevent displacement.
System Activation
1. Insert the posterior part of the wire distal to the tipped molar tube
(Figure 16A-B).
5. In this case a force is generated to distalize, intrude and rotate
the molar counterclockwise.
6. Wait until the uprighting is completed and it can be finished with
braces if necessary (Figure 21A-B).
16A
16B
Figure 16A-B: Insert the wire from behind the tube.
2. Pull and engage the elastic on the hook (Figure 17A-B).
20
Figure 20: Second molars impacted against the first molar.
17A
17B
Figure 17A-B: Pull the chain and engage it as close as possible to the tube or band,
cut the extra.
3. Push the wire and place the loop around the head of the mini
implant making pressure on the tipped molar (Figure 18A-B).
21A
21B
Figure 21A-B: Molar uprighted in less than four months with very few appliances.
System Deactivation
1. Cut the elastic from the hook.
2. Break all the bonding material over the mini implant head with a
hard wire cutter.
3. Remove the loop from the head.
4. Pull out the wire from the tube or band.
18A
18B
Figure 18A-B: Engage the wire in the mini implant head, an intrusion and
distalization forces are applied to the molar.
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5. Use the driver to engage the implant head and then rotate it in a
counterclockwise direction until it is sufficiently loose to remove
with a cotton forceps9.
Conclusions
It is important to understand the strengths and limitations in
mini implant treatment. MIST should be further developed with
the experience of doctors interested in this field, and each time
include more effective procedures and methodologies, such as the
parallelization of molars. In this article I have tried to show how to do
this treatment with just a few appliances, putting the mini implant
in a safe, accessible area, and with emphasis on patient comfort,
which is one of the most important premises in the system. If you
would like more information on the MIST System, there is further
discussion on my website, www.ortoimplantes.com.mx.
[Note: Currently in Spanish, English version being developed. – Editor]
Regarding the selection of the brand of mini implant to use,
I am convinced that the Unitek™ Temporary Anchorage Device
(TAD) System is a great choice. Unitek TADs belong to the
self-drilling and self-tapping group, we can get all the instruments
required to place them in any area, and Unitek TADs have a
diameter of 1.8 mm, which makes a fracture extremely unlikely.
We can also take advantage the Unitek™ TAD O-Cap to make a
laboratory apparatus, or simply to give the patient greater comfort.
But one characteristic I really like is that I don't need to inventory a
huge stock of the implants, because with just 3 measures, 6, 8 and
10 mm, I can place a reliable implant in my patients.
I would like to thank Dr. Mohammed Razavi and Dr. Jair Lazarin for
their help and support in the preparation of this article.
Case photos provided by Dr. Jose A. Trespalacios.
References
1. Favero L, Brollo P, Bressan E. Orthodontic anchorage with specific fixtures:
related study analysis. Am J Orthod Dentofacial Orthop 2002;122:84-94
2. Baumgaertel S, Razavi MR, Hans MG. Mini implant anchorage for the orthodontic
practitioner. Am J Orthod Dentofacial Orthop 2008;133:621-7
3. Shellhart C, Moawad M, Lake P.Case Report: Implants as anchorage for molar
uprighting.. Angle Orthod. Int. 1996;169-2
4. Sawika M, Racka-Pilszak B, Rosnowska-Mazurkiewicz A. Uprighting Partially
Impacted Permanent Second Molars. Angle Orthod. 2007;77:148-4
5. Grover PS. Norton L. The incidence of unerupted permanent teeth and related
clinical cases. Oral Surg Oral Med Oral Path. 1985;59:420–5
6. Mead S. Incidence of impacted teeth Uprighting. Angle Orthod. Int J Orthod
1930;16:885-0
7. Henns R. Uprighting Impacted Mandibular Second Molars. Angle Orthod.
1975;45:314-5
8. Park HS, Kwon OH. Non extraction treatment of an open bite with microscrew
implant anchorage. Am J Orthod Dentofacial Orthop; 2006;130:391-02
9. Herman R, Cope JB. Miniscrew implants: IMTEC mini ortho implant. Semin
Orthod. 2005;11:32-9
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